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HEALTH Connections

Michael FineJames McDonaldChristina StanleyNicole Alexander-ScottUtpala BandyTwila McInnis

From the Director

Here are14 ways health professionals can help Rhode Islanders get and stay healthy in 2014 and can make Rhode Island the healthiest state in the Union.

From the Board of Medical Licensure & Discipline: Rules of the Road

Receiving a notice that a complaint has been opened regarding your medical license is never a pleasant experience. Not every complaint can be avoided, Here are some tips to avoid some of the more common complaints.

Guest Column: Thoughtful Opiod Prescribing: Balancing Pain, Addiction, and Mental Stability

Amessagefrom Dr. David Kroessler

Health Advisory: HEALTH Declares Flu Widespread in RISyringes filled with vaccine

On January 8, HEALTH and CDC declared flu to be widespread in the state. The most common circulating strain is H1N1, a strain that is impacting younger people more than the elderly. The H1N1 strain is included in this year’s vaccine, so it should protect individuals who have already been vaccinated.

  • Clinical providers should review the mandate currently in effect for masking for healthcare providers who are un-vaccinated when flu is widespread.
  • Report any influenza-associated deaths, any influenza-associated hospitalizations, any influenza novel virus infections, and any influenza-like illness institutional clusters (two or more cases within four to five days) to HEALTH’s Division of Infectious Disease and Epidemiology. (Call 222-2577/272-5952 or fax to 222-2488.)
  • Identify unvaccinated patients and vaccinate, or refer patients to HEALTH’s Information Line at 222-5960.
  • Be aware of the community vaccination clinics throughout the state.
  • Check weekly surveillance reports.

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Pharmacy HEALTH Connections
News from the Board of Pharmacy

Michael Fine James McDonald Stephen Kogut Pharmacist Campbell Dr. Kelly Orr

Message from Director Fine

Dear Colleagues,

We are delighted with this, the inaugural edition of HEALTH Connections for Pharmacists.

Pharmacists are the Rhode Island healthcare boots on the ground, and pharmacists work where the Rhode Island healthcare rubber meets the Rhode Island healthcare road. There are pharmacists in every Rhode Island community, and every Rhode Island hospital. Pharmacists talk to and counsel every Rhode Island patient, and oversee the safety of all Rhode Island medications. Pharmacists now give almost one fifth of all our influenza vaccinations, and have been critical to our strategy to increase influenza vaccination in Rhode Island, which has increased by eight percent in the two years since pharmacists joined the ranks of our vaccinators – although we have a long way to go (even with the grand collaboration we have built on influenza vaccination, we still vaccinate only half of all Rhode Islanders, which means we left 500,000 people unvaccinated in 2013-2014). Pharmacists help us control the twin epidemics of diabetes and heart disease in Rhode Island, helping us oversee medication compliance and helping us promote diet and exercise. Pharmacists are key players in helping us make hospitals as safe as possible, overseeing quality assurance, calculating dosing, double checking medication safety and preventing the administration of medications that are likely to interact. Pharmacists have a critical role in primary care practices and in nursing homes, helping to reduce polypharmacy while preventing drug interactions in those settings. Pharmacists are helping us control the epidemic of prescription-overdose death, by providing oversight of all Rhode Island opiate and benzodiazepine prescribing and by enrolling in Rhode Island’s prescription monitoring program and checking the electronic record for every patient who has been prescribed an opiate or a benzodiazepine. And now, pharmacists are leading the way out of the epidemic of smoking and tobacco addiction, by courageously removing tobacco products from many Rhode Island stores, a Rhode Island innovation lead by great Rhode Island pharmacists, who proved, yet again, the commitment of pharmacists to the health and safety of all Rhode Islanders.

I can’t tell you how much respect we have for the work pharmacists do, every day and every night in Rhode Island, in every corner of the state. You are the eyes and ears of healthcare, our watchmen and women and the guardians of our safety. Healthcare is a collaborative enterprise, and HEALTH Connections, to the extent it is effective, will be effective only if it can support and honor the work you do every day and every night.

Thank you for that service, and for always putting patient care first.

Michael Fine, MD
Director

From the Chair, Board of Pharmacy.

Dear Colleagues,

The members of the Rhode Island Board of Pharmacy are pleased to have the opportunity to provide content for this newsletter and improve communications regarding ongoing activities and changes related to the pharmacy practice in the state.

As many of you are aware, rules and regulations change frequently and it’s critical to have this forum to continually update pharmacists, technicians, and interns. Last month, proposed regulations for the Prescription Monitoring Program (PMP) and electronic prescribing of controlled substances went under community review and will be moving forward. We expect to report on the progress of these, and other, regulations.

In upcoming issues, we hope to highlight advancements in practice such as transition of care models and compounding initiatives.

We welcome our colleagues to attend monthly Board meetings – scheduled for the third Thursday of each month, 8:30 a.m., Department of Health, Cannon Building, 401 Conference Room. The open session agenda is posted two days prior to the meeting on the Department of Health’s website. Open session is held in accordance with provisions of the RI Open Meeting Law and anyone may attend.

Kelly Orr, PharmD
Chair, Board of Pharmacy

Topics in Pharmacy Practice -Pharmacy's Role in Supporting Care Transitions

Pharmacists have a long-standing role in supporting the medication management needs of patients returning home after a hospitalization. In recent years, new requirements for medication reconciliation have placed added emphasis on reviewing medication lists and resolving medication-related problems before patients are discharged from the hospital. Other initiatives are utilizing community pharmacists to ensure that recently hospitalized patients understand and adhere to new medication regimens. National heath reform efforts have highlighted the need to improve coordination and communication during care transitions, which are typically defined as a change in a patient's care setting or provider. Health insurance programs and care providers recognize the critical role of medication therapies in preventing costly rehospitalizations. Pharmacists across all settings can expect increased opportunities to provide services for patients experiencing care transitions. Pharmacists seeking to learn more about services to promote effective care transitions are encouraged to refer to a white paper jointly developed by the American Pharmacists Association and the American Society of Health Systems Pharmacists, entitled Improving Care Transitions: Optimizing Medication Reconciliation. The Department of Health appreciates the essential role of pharmacists in promoting the safe and effective use of medication therapies during care transitions. These efforts significantly enhance the health and quality of life for all Rhode Islanders.

Stephen Kogut is a Professor of Pharmacy Practice at URI and is a part-time consultant for HEALTH's Pharmacy Program.

Pharmacy Board Staffing Shelves at pharmacy with pill bottles

A message from Donna L. Costantino, MBA

The Department of Health is pleased to announce that Stephen Kogut, PhD, RPh, Professor of Pharmacy Practice, has joined the team at HEALTH on a part-time basis through an agreement between the University of Rhode Island and the Rhode Island Department of Health. Kogut is a registered and practicing pharmacist and is providing support to the Pharmacy Program staff and to the contractual pharmacy inspector on matters relating to state and federal laws governing the dispensing of drugs and pharmaceuticals.

Kogut specializes in the area of pharmacoeconomics and managed-care pharmacy. His teaching contributions span across a range of topics, including health economics and policy, public health, and healthcare systems. Locally, he is involved with the Rhode Island Medicaid pharmacy program and with Healthcentric Advisors, the state’s Medicare-contracted Quality Improvement Organization. Kogut is a member of the Rhode Island Medicaid Drug Utilization Review Board, and is a former member of the Rhode Island Board of Pharmacy.

HEALTH’s Pharmacy Program has also contracted with Scott Campbell, RPh., CDOE to perform inspection and investigation services on a per diem basis. His work will include inspections for pharmacy openings and investigations involving diversions and improper handling of pharmaceuticals.

Campbell received a bachelor’s degree from the University of Rhode Island, College of Pharmacy and has worked in community pharmacies for 36 years. He opened and operated two pharmacies (Ocean Pharmacy in Richmond and in Charlestown) with his business partner, Kathleen Kettle. Campbell says his passion is pharmacy (especially independently-owned pharmacies), and he looks forward to helping and educating pharmacy owners on the business aspects of pharmacy.

HEALTH is in the process of recruiting a Pharmacy Program Chief to oversee staff engaged in the licensing, inspection, and regulatory activities for pharmacies, and for a full-time Pharmacy Inspector. During the recruitment process, Donna L. Costantino, MBA, Chief of Health Professions Regulation, will serve as acting administrator for the Pharmacy Programs. She has been employed at the Department of Health for 22 years and is triaging and prioritizing pharmacy issues and works closely with Kogut and Campbell.

Why Use The Prescription Monitoring Program (PMP)? Graph of overdose deaths from illicit drugs and prescriptions

Every pharmacist and every provider who has a license to prescribe controlled substances should use the Prescription Monitoring Program (PMP).

Why? The numbers don't lie...
Learn more from James McDonald, MD, Chief administrative Officer for the Board of Medical Licensure and Discipline.

Reasons To Register For The Prescription Monitoring Program (PMP)

Yes, I’m writing about the PMP again. Want to skip reading the entire article and keep me happy? Register for the PMP and use the PMP before dispensing a controlled substance.

In 2013, 358,753 individuals filled a prescription in Rhode Island for a Schedule 2, 3, or 4 medication. That is more than one third of all Rhode Islanders. The chart posted in the newsletter illustrates the total number of non-liquid doses of controlled substances prescribed in 2013.

More than 90 million non-liquid doses of schedule 2, 3, and 4 medications were filled at Rhode Island pharmacies in 2013. I am not sure that 90 million doses of a controlled substance seems like a lot to you or not, but it is. One way to look at it: there were enough controlled substances prescribed last year so every Rhode Islander could have 90 doses. Interestingly, almost half of those total doses were prescribed for pain, meaning enough opiates were prescribed for each and every Rhode Islander to have 45 doses!

What’s even more alarming to me, as a prescriber of controlled substances, is that in 2013, 1,394 individuals filled a prescription for a schedule 2, 3, or 4 drug from five or more prescribers and used five or more pharmacies. Let’s try to get our arms around that fact. Is there really such a large group of people who had reason to receive a controlled substance from five or more prescribers? And go to five or more pharmacies to get those prescriptions? There could be a legitimate reason for that, but as a prescriber, I would want to know about it and have the opportunity to discuss it with my patient.

Unfortunately, statistics like these raise suspicions of diversion - when a pharmaceutical prescribed for legitimate reasons is shunted or directed for another purpose. If you register and use the PMP, you could identify these patients before you dispense to them and unknowingly contribute to diversion. The PMP is a two-way communication tool. We at HEALTH can notify you of individuals we suspect may be diverting prescription drugs.

Here are some more numbers to consider regarding the issue of controlled substance prescribing in our state. In 2013, 19,068 individuals were on a morphine equivalent dose of greater than 100 mg per day. Interestingly, 87 children were on a morphine equivalent dose of greater than 100mg per day. Patients on morphine doses greater than 100mg per day are at a much higher risk for overdose.[i] This is a large dose of opiods and comes with attendant risks for overdose, diversion, and addiction.

What you don’t know about your patients can hurt them. It is your duty to be vigilant when you dispense a controlled substance and check the PMP. It is the expectation of the Director of Health that the PMP is reviewed before a prescription for a controlled substance is dispensed.

So, if you are still with me, undoubtedly, at this point you want to know how to register for the PMP. Visit the registration website, complete the form, have it notarized and email it to us along with a photo of your driver’s license. We will issue you a user name and password in a jiffy.

Using the PMP is rather intuitive. All you need to get a “New Report” is a patient name and date of birth and decide if you want the report in Excel or PDF format. The reports usually appear in a few seconds and give you a nice picture of what you patient’s controlled substance history has been for the 12-month period you select. There is also a PowerPoint tutorial on using the PMP on HEALTH’s website.

In order for the PMP to make the impact it was intended to have, any pharmacist who is licensed in Rhode Island should enroll in the PMP. Our goal is to have 90 percent of eligible providers enrolled by December 31, 2014. We are counting on you to help us reach that goal.

Spotlight on: OTC Box of oxytrol for women

Each month, we’ll feature an issue relevant to over-the-counter (OTC) medications. Community pharmacists are on the frontline of patient care with an ever-expanding class of OTC medications. Pharmacists must familiarize themselves with the self-care indications for OTC medications and know when to refer the patient to his or her primary care provider (PCP).
This month, Pharmacist Ginger Lemay discusses Oxytrol ® for Women.

Join Rhode Island Pharmacies And Say No To Tobacco! No smoking graphic

HEALTH applauds all Rhode Island pharmacies who made the courageous decision to stop selling tobacco products and have taken a stand for people's health. In addition to CVS Caremark, we recognize JB Health Mart #1 in Providence; JB Health Mart #2 in North Providence; Newport Health Mart Prescription Center in Newport; Baker’s Health Mart in Jamestown; Ocean Health Mart in Charlestown; Blackstone Health Mart in Pawtucket; Phusion Health Mart in Coventry; Vita Scrip in Providence; and McQuades in Westerly. You are trend setters and should all be proud!

Rhode Island's PMP...Did You Know? Pile of pills

Rhode Island’s Prescription Monitoring Program (PMP) is a great resource for prescribers and for pharmacies to help avoid opioid abuse or misuse. Currently, there are 2,110 licensed pharmacists in the State. Of those, 430 pharmacists have enrolled in the PMP. We'd like to get that number up to 1,900 by the end of 2014. Enroll now and please check the PMP before filling a schedule 2, 3, or 4 medication.

What is A Medical Order For Life-Sustaining Treatment (MOLST)? MOLST logo

This is a new clinical tool to facilitate end-of-life dialogue with patients who are terminally ill. Regulations for use of the MOLST in Rhode Island went into effect with the new year. A MOLST is a form that an authorized provider (MD/DO, APRN, or PA) completes jointly and with the patient's (or their healthcare decision maker) consent and represents the patient’s wishes regarding end of life care. (MOLST is only appropriate when patients are terminally ill.) The MOLST form is a durable and portable document that transcends the point of care and is valid in a patient’s home, the emergency room, a hospital, a nursing home.

Memories of Dr. Milton Hamolsky Dr. Milton Hamolsky

Dr. Milton Hamolsky, the first Administrator of Rhode Island’s Board of Medical Licensure from 1987 - 2001, died on January 18 at the age of 92. In his medical and professional career that spanned nearly seven decades, he influenced and touched the lives of scores of healthcare providers and Department of Health employees. Two former Medical Board staff have written tributes to share.

We Want Your Feedback! Graphic

Pharmacy HEALTH Connections will be published and distributed electronically the first Wednesday of every month. Our goal is to share updates and public health news that is relevant to pharmacies and pharmacists. If you have a question or issue that you would like addressed, please email Annemarie Beardsworth.

Five Things Every Pharmacist Can Do To Make RI the Healthiest State

  1. Help prescribers and patients choose wisely. Encourage and support prescribing of medications that are necessary and be acutely aware of prescribing for opioids and antibiotics.
  2. Ask every patient to stop smoking. Ask patients to help family and friends quit smoking too.
  3. Listen. Patients may approach you with questions or concerns about substance abuse or prevention. Know the signs and be familiar with available resources in the state.
  4. Practice prevention. Make prevention a priority at every patient interaction.
  5. Open and read Pharmacy HEALTH Connections every month. This newsletter will be distributed the first Wednesday of every month. Don’t forget to check upcoming topics for Public Health Grand Rounds.